TMS Patient Packet

Atkinson Family Practice

17 Research Dr., Amherst, MA 01002

413-549-8400

Dr. Nora Schwartz Martin
TMS Welcome Packet

We feel we have something very special here at Atkinson Family Practice and we look forward to caring for you. Let us tell you more about ourselves and our philosophy regarding patient care.
We are very excited to offer TMS at Atkinson Family Practice. We are an integrative practice that fully believes in healing minds and bodies. We believe TMS is a great addition to the services we offer and are so glad that you chose us for this journey. Below are some key policies that can help keep your appointments running as smoothly as possible.

Appointments: We ask that you give 24 hours' notice if you are unable to make any appointments. We try to schedule these as far out as possible and have extended hours most days to t ry and accommodate most schedules. We understand that sometimes things come up that are unavoidable and just ask for as much noticed as possible. If you do cancel or no show an appointment there is a $50 fee. We may waive the fee if only one appointment is missed. In addition, if you are fifteen minutes late or more to an appointment, we cannot guarantee that we can see you that day. We frequently book back-to-back appointments so it is very important that you come to all of your appointments on time. If you are going to be late please call to inform us. We may ask you to reschedule or cancel your appointment.

Insurance: There are many, many insurances each with many different programs--we cannot know what your insurance actually covers. You are responsible to know what your policy states. We will work with you to find out your financial responsibility and obtain a prior authorization; however, these are not a guarantee of payment. We do not set your co-pay or deductible--your policy does. After your insurance has paid we will expect you to pay the balance in a reasonable amount of time. We have dedicated billers who are available if you have any questions. We will generally work out a reasonable payment schedule during your mapping visit.

Payments: We count on your payments to keep our office operating. You are responsible for paying for your own medical care. We sign contracts with your insurers agreeing to collect co-pay, so we are not able to waive them. We would appreciate your not asking us to do so. Please note: If we have to send a statement after treatment there may be an additional fee of $10. If a check is returned for non-payment, there will be a $30 bounced-check fee applied to your account and check writing will be prohibited with our office.

PHONE: Our office phone is 413-549-8400. Our phones are on weekdays 7:30am to 7:00pm Monday through Thursday and 7:30am to 5pm on Friday. We are off for lunch from 12:30-1:30pm every day. You may leave a message with the front desk for our TMS coordinator or Dr. Nora and we will respond within 24 hours.

EMAIL: You can email Kimberly, our TMS Coordinator at krose@doctorkate.net. She will forward any correspondence to Dr. Nora directly.

List of Medications
Please list patient's regular daily medicines (including dosages):
Please list patient's supplements (including dosages):
Please list medicines that patient takes only occasionally (including dosages):
Please let us know your preferred pharmacy
Address
Phone Number

Area CodePhone Number
Patient's Name

First NameLast Name
Patient's Date of Birth

Statement of Understanding

Assumption of Financial Responsibility for Medical Services
I am enrolled in the following insurance plan(s):
Primary
Insurance ID #:
Secondary
Insurance ID #:
Tertiary
Insurance ID #:
I acknowledge that I have voluntarily sought the services of Atkinson Family Practice, a participating provider. I accept full responsibility for paying for services provided by Katherine Atkinson, MD, PC. I understand that my insurer will not pay the provider nor reimburse me for the cost of services rendered here, or for any subsequent or ancillary services which the provider may order on my behalf, if this insurance is not truly in effect or if the provider is not considered my primary care physician. I further acknowledge that it is my responsbility and not the provider's to know what services are covered by my insurer. I accept full responsibility for paying for services provided if they are not covered by my insurance. If the above information changes at any point, it is my responsibility to notify Atkinson Family Practice.
Patient Name
Date of Birth

MonthDayYear
Date
Responsible Party's Signature

Clear
Date
Assignment and Release
I certify that I and/or my dependents assign our insurance benefits directly to Katherine J. Atkinson, MD, PC. I understand that I am financially responsible for all charges whether or not they are paid by the insurance company. I authorize the use of my signature on all insurance submissions. I certify that Katherine J. Atkinson, MD, PC and its employees have the right to disclose my (or my dependents') health care information to my insurance company and their agents for the purpose of obtaining payment for services and determining insurance benefits and payments for related services. This consent will remain active unless I cancel it in writing.
Signature of Patient, Parent, Guardian or Personal Representative

Clear
Date

MonthDayYear
Date

	Name	Phone Number	Relation to Patient
Person 1
Person 2
Person 3
Person 4

TMS Welcome Packet

TMS Patient Form

List of Medications

HIPAA

Statement of Understanding

Authorization for Release of Medical Information

Quality of Life Scale (QOL)

Beck's Depression Inventory